ACS —Warding Off Tragedy

“John, Dr. Williams is dead. I thought you’d want to know.” The news hit me like a thunderbolt. The caller was an FAA inspector. Just two weeks earlier, I had asked him to talk with Dr. Williams. Dr. Williams was a towering figure. He was a physician, a radiologist and an Episcopalian priest. He was a pillar in his community. But as a pilot, he had worried me.

Martha and I were teaching two-day ground schools, and Dr. Williams had been in my class. He just didn’t follow the normal conventions of classroom behavior. He was impatient and in a hurry. He returned late from breaks and blurted out comments in class. I was worried he might behave impatiently in his flying. In fact, I was so concerned that when the FAA inspector came to administer the knowledge test, I asked him to speak to Dr. Williams.

“John,” my FAA friend said, “I can’t just pick someone out of your classroom and lecture him because you told me I should. He’ll call his congressman. You talk to him.”

“He won’t listen to me,” I said. “I’m just a traveling ground instructor.” So neither one of us talked with him.

He died on a solo cross-country. On the first leg, he got lost and wound up in the mountains. Asking for help on the radio, he said, “There are clouds around me with trees in them.” He landed safely at his destination.

Greatly relieved to see him, the folks at the Flight Service Station literally begged him to come in to talk. He didn’t have time, he said. He was scheduled to make a speech after he returned to his home airport. Without shutting off his engine, he took off on the return leg. He died in the same mountains on his way back.

I was devastated. I felt terribly guilty. I had foreseen that this might happen, yet I hadn’t spoken to him. I considered quitting teaching flying. I felt that I didn’t want to continue teaching people to do something that could kill them. Martha and I were traveling on a circuit of cities, teaching more than 2,000 pilots a year. All too often we returned to a city to learn that a pilot we knew had died. It was getting to me, and Dr. Williams was the tipping point.

Moreover, I was deeply discouraged that many of the questions we needed to prepare pilots for on the knowledge test were obscure, trivial and even tricky. As a result, we were being forced to teach obscurity while pilots were coming to grief because they did not know how to identify and mitigate the risks of flying. Being part of that failed and dysfunctional system was depressing.

I loved flying and loved teaching it. It would be, I decided, my job to teach pilots how to identify and mitigate the risks of flight. I made one more resolution: I would never again fail to speak out when doing so offered any chance of saving someone’s life.

The unanswered question is: What would I have said to Dr. Williams that would have gotten a positive result? I still don’t know. That’s probably the real reason neither my FAA friend nor I spoke with him. An even more pertinent question is: What, if anything, could have been done to head off that catastrophe? I believe the answer would have been to teach him aviation risk management, but it would have needed to start with his first flight lesson.

Physicians are not unaccustomed to the idea of managing risk. Dr. Williams had been a radiologist. There are all sorts of risks associated with radiology. Dr. Williams and other goal-oriented people can develop the habit of identifying and mitigating risks in aviation as they do in the rest of their lives if that habit is cultivated from the very first flight lesson.

The Flying Magazine interview that Lane Wallace conducted with John King that preceded a change in tone and focus in the aviation industry.

As time progressed, it became apparent that Martha and I were far from the only people who had these concerns. In the March 2001 issue, Flying published an interview of me by Lane Wallace titled “Battling the ‘Big Lie.’” This gave me the venue to speak out to the aviation community. I wanted pilots to know that we should recognize that the activity of flying is risky, and we should manage the risks. It was a provocative interview, and it took courage for Flying editor Mac McClellan to run it.

In response to the story, Jim Lauerman, head of Avemco Insurance, wrote a letter proposing that we work together to help pilots manage risks. The folks at Avemco had been mourning the all-too-often loss of pilots and customers as Martha and I had. In response, we developed a series of practical risk-management courses, and Avemco grants a premium credit to pilots who take them.

At about the same time, Bob Wright, who was head of the FAA’s General Aviation and Commercial Division, spearheaded the implementation of the FAA-Industry Training Standards (FITS), with a goal of incorporating scenario-based training and risk management into flight training programs.

Still, the accident rate remained high, and the FAA knowledge tests continued to be profoundly irrelevant. In May 2011, the Society of Aviation and Flight Educators (SAFE) organized a landmark conference in Atlanta, which brought together hundreds of concerned pilots and instructors. Among them was Van Kerns, head of the FAA’s Regulatory Support Division, which is responsible for airman testing standards. Van listened while person after person railed about the poor quality and irrelevance of the knowledge tests.

That evening Van bumped into Susan Parson, who is special assistant to the Director of the FAA’s Flight Standards Service. Susan, always deeply disturbed by the irrelevance of the exams, was by then steaming as result of the ATP written exam she had recently taken. Van and Susan agreed that this needed to change.

Susan recruited folks from nearly every segment of the aviation training community, including even me, and the right people from the FAA, and set us all to work. The result of the five-year effort from the ARC and the two ACS Working Groups that followed was the development and implementation of the Airman Certification Standards (ACS). The ACS incorporates everything a pilot is required to know or be able to do for a specific certificate or rating into a single document.

I am delighted to report that beginning in June, the ACS will replace the Practical Test Standards for the Private Pilot-Airplane and Instrument Rating-Airplane practical tests.

The first thing folks will notice when they prepare for a check ride is that now, for the first time, there are standards for the knowledge a pilot is expected to demonstrate on both the knowledge test and practical test. The knowledge required of pilots will be relevant to a pilot’s ability to get utility from the aircraft, and to identify and mitigate the risks of flight. No longer will the pilot be tested on the trivial and obscure.

Plus, a pilot will be evaluated on the ability to actually apply the knowledge they have learned to identify and mitigate the risks of flight. Pilots with this habit will be situationally aware and far less likely to be caught by surprise by events that, with risk-management skills, they would have seen coming.

I now have hope that extremely goal-oriented pilots like Dr. Williams will get the help they need to ward off tragedy. If the ACS had been in place when Dr. Williams was learning to fly, perhaps he would have learned to identify and mitigate the risks associated with scheduling a speech right after a solo cross-country.

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50 thoughts on “ACS —Warding Off Tragedy”

Your article gave me a little twinge in my stomach. I think mostly from not knowing what to expect but being glad that the reality of flying takes a good student and one able to use all of the things learned that are at his or her finger tips. I am very goal oriented and realize that flying is a serious although I’m sure enjoyable experience.
I train people in my business and it is important that they listen and learn . although their mistakes are costly to them and to me they are not near as costly as Dr. William’s.
This was good to read as it puts things into perspective.

Thank you for highlighting this important issue. As a flight instructor, we run into similar pilots from time-to-time. At least you have provided encouragement to be proactive with this issue. Hopefully the new approach with the Airman Certification Standards will assist with making safe pilots. Thanks again.

I lost my copilot and friend 2 weeks ago after he lost control at take off in a CE 550. I always told him to run the PAVE checklist before every flight, he never did when he flew with someone else because I had him checklist whipped every time we flew. Well on this sunny afternoon he took off in a defective airplane and with passengers pressuring him to go pick them up. Well he departed the first time and aborted because the Clamshells deployed on the right side. Tried again and got killed in a LOC-I. Always bother fellow pilots on safety and if for whatever reason you just don’t feel like flying. Go home and forget the angry folks you leave behind. At the end you’ll be alive to hear the bickering.

Great article. I’ve not gone over the ACS in sufficient detail yet to understand the changes. One comment I have regarding GA pilot training…why not look at the military model and use the lessons learned there? I came from a military pilot background- All of my aviation training from first solo onward was by the Navy and Marines. When I left the service I was shocked by the casual attitude of GA pilots and instructors. No pre-flight briefing? No formal debrief? No discussion of ORM? I think there are a lot of habits that military pilots learn from the very beginning that should carry over to civilian flying. One BIG one I have tried to share with other pilots is the pre-flight brief. It’s very detailed but once you learn the format it’s no big deal. You just run through the outline and make sure everything is covered. Most GA pilots just say, “let’s go fly.” That isn’t enough. Even solo pilots should brief themselves before flight.

King Schools new private pilot and instrument (online) checkride practical test courses are modeled after the ACS style checkride. If you are taking your checkride in a couple of weeks, you’ll want to make that purchase now.

John, you and Martha continue to educate pilots around the country in multiple ways! I’m always learning things from you both in flying magazines, at aviation meetings where you present, etc. Thank you both for your wonderful contributions to safe flying!
Dailey – and I happen to be an MD as well! (:>)

Very well said, and the 2001 article was excellent. Soaring magazine has recently had some very direct articles on the risks of glider flying, so perhaps that indicates some changes in at least that sector of general aviation too. But on a wider level this topic of risk deals with how American culture perceives the issue. For a number of reasons too long to go into here my opinion is that most citizens have been infantilized into not being willing to accept any risks in their lives (hence fear of largely nonexistent predators, terrorists, etc. followed by massive and unquestioned over regulation). One result of this situation is that many people think being risk free is the ideal way to live and so are not well able to recognize danger when it exists (which could be one factor in drunk driving and also why idiots feed the bears at Yellowstone). To have a sport that many people participate in and freely admit is slightly dangerous is so far outside this ordinary mindset means that it is going to take a lot of rethinking by pilots to have most of them honestly admit it. And I don’t know what that will do to government or the non-flying public; more rules? Less people willing to learn to fly? Perhaps, perhaps not. That said, in my opinion what you are saying and doing is absolutely right and completely necessary. It will just take time, patience and perhaps even a new generation to really get there.

“Physicians are not unaccustomed to the idea of managing risk.” I enjoyed your parable up to the point where you brought in this time-honored cliche. The concept that physicians are not accustomed to risk management rolls off the tongue easily enough, but there’s just not any good supporting evidence to single out physicians as a disproportionately reckless bunch of risk takers. Every profession has its share of unteachable individuals without common sense or good judgement, if any judgement at all. Maybe the subject of your story was testing his Episcopalian creds, and that got him in to trouble. Normally I would just ignore this kind of comment in an otherwise useful flying story, but sitting down for a minute near the end of an apparently swashbuckling day of physician-ing, I started reading through your story and picked up this pebble in my shoe. When you are as good as YOU are, some of us expect the best of you at all times, and this cliche just rankled me enough to write. Now that that’s done, I’m going out to the airport to work on night currency, as it is a beautiful evening to fly.

JHA. I think you misunderstood….
He said,
“Physicians are not UNaccustomed to the idea of managing risk.”
Meaning he’s saying that physicians often deal with managing risk… Which is why John was surprised with a partitcular Dr’s lack of managing risk when it came to pilotage.

You need to read a bit more carefully before accusing Mr. King of a “cliche.”
“Physicians are NOT UNACCUSTOMED to the idea of managing risk.” That means “Physicians ARE ACCUSTOMED to managing risk.” The double negative equals a positive.

This is truly positive and forward thinking, overhauling the tests and test standards it is way overdue in light of new technologies but also in the area of risk management. I have always disliked the long over used challenge/answer approach used by almost all flight instructors. You are given several incorrect pieces of information along with the correct material and it is up to you to decipher the best response. Why not just teach the correct response and use scenario training. Misinformation is used very nicely by questionable organizations…but why confuse students with bad info. Let’s be upfront and just teach the correct way of doing things: practical, correct skills and tests and scenario management. Right? Wrong? Mabye? ; )

i read it 50 times. on the 51st read i see it says “not UNaccustomed”. Whew. You got it right the first time, so you are still on my favorite writers list! But i’m still gonna go practice in the sky this evening…All best wishes!

I am, oddly enough, a physician and radiologist, too. Towering? Well, two out of three …

Not to feed into the stereotype, but I have known so many dangerous physician-pilots (One almost killed me and my girlfriend when I was in med school, with a VFR-into-IMC encounter) that when I sign up for training at another airport, I NEVER put “physician” on the intake form. It’s usually “consultant” or even “X-Ray technician.” Ditto in the airplane if the instructor asks what I do for a living. Once you say, “doctor,” they never say a word, but you can see the wheels turning in their head and your being slipped into a slot in their brains. I want to be judged by my skills and more importantly my attitude, not my profession’s bad reputation.

My mantra, which I spread everywhere, is: anybody can learn to DRIVE an airplane. Judgement makes a pilot. While not true of all, or even most physicians, the hurried, impatient, always-in-control attitude is common, and after my harrowing IMC experience with a low-time surgery resident, until I became instrument-rated and could take over if necessary, my inviolable rule was that I never again flew with doctors as PIC. Ever.

” my inviolable rule was that I never again flew with doctors as PIC. Ever.”
Does that mean you quit flying ?
If you do fly, you are braking your own rule.
Naturally speaking : You are a Doctor and a PIC when you fly solo.
Are you not ?

The chart have still NOT been corrected in the Figures book. Density Altitude chat does not match up with standard line as well as you can not use N.M. since the charts were blown up to a larger scale. Also some of the color charts are nice but when you are following performance graphs, the old black and white were much easier to follow. I teach private ground school and I think this should have been addressed ASAP by the faa!

Thank you,
I am currently studying for my instrument rating.
Will King Schools be updating their written test prep study materials to assist us in preparing to pass the new risk management based tests.

King Schools courses cover the subjects the FAA wants you to know. Our customers are reporting good success on their tests after studying their King Ground School and Test Prep courses since they have been taught the concepts. When we learn of changes to what the FAA wants pilots to know, we update our courses. If you have an online course, your course is updated automatically if there have been changes that affect the knowledge you need to know.

I am a surgeon. We deal with risk all the time and are hugely goal orientated and often very poor at mitigating risk.

I fully support the changes.

Sadly though I just signed up and received your commercial pilot training courses and they are out of date in the extreme, and that is being polite – they talk about weather on 20 year old videos using obsolete equipment. I was VERY disappointed.

I would challenge you to put yourself to the task of making these courses up to date and relevant to the new standards.

Happy to discuss with you any time as I teach and lecture to surgeons.

Your comment is important to us. We are currently in the process of updating our courses to HD to give them a more modern look and feel. We started with the Private Pilot courses and are now starting with the Instrument Rating courses.

Most importantly, the knowledge taught in the course you have is the knowledge the FAA expects you to know and the same knowledge that you will be tested on. While the appearance is dated, the content itself is not. When we learn of changes to what the FAA wants pilots to know, we update our courses. If you are not satisfied with your course, we do offer a 30 day, no questions asked return policy. Our goal is to ensure you are satisfied with your purchase and that you pass your FAA exam. Please contact our Customer Service Department at 800-854-1001 if you would like to return your course.

Good job. As a Navy NATOPS instructor and evaluator, at the Squadron and Wing level in the 1980’s and 1990’s, level I always pushed to remove the “Trivia Pursuit” questions, especially in the Closed Book exam. They ended while I was overseeing them, then cropped back up when I transferred. Later I twice challenged the validity of the tests, once while attached to a R&D command where the Commanding Officer ended up kicking the LANTFLEET evaluation team out, later at the Squadron level when the LANTFLEET NATOPS Team gave PATWING 5 personel a closed book test where 70% of the questions in the closed book questions dealt with equipment that none of the Squadrons had. Might as well asked questions on the F4 vs P3. Later, at VP-31, after a class A accident where the PACFLT NATOPS Pilot Evaluator attempted a “Penetration Approach”, ie a obstical and soft field approach for you civilians, practicing for the final Moffet Field Airshow. Flared late, drove both main gears through the wings, lucky all the crew was in the cockpit and exited the aircraft through the overhead hatch. During the investigation it was found he was not current in the aircraft. After that, FLEET NATOPS EVALUATION teams were disestablished. The Squadron NATOPS evaluation was delegated to the Wing Commanders. I retired about that time (1993) but I HOPE the “Trivia Persuit” attitude has been toned down, and attention is paid more to the Safe Operation of the aircraft.

Thank you. I was a military pilot, Delta captain and still a corporate pilot and hot air balloon pilot. This new method of evaluation of pilot decision-making is a step in the right direction, finally!
In the ballooning world, there is no such thing as a CFI, so discussions concerning risk management may or may not exist in the weak training environment.

Great food for thought. I too am working in a high-risk industry, but hadn’t seen the risk management link so clearly until I read your article. I am learning to fly; it has seemed to me until now that many of the educational materials I’ve worked with are aimed at stuffing your head with data, not placing that data in an overall context of managing the risks involved in flying. From now, I am going to study these materials in a context of “How does this help me manage the risks?” Thank You!

For all the positive points in this story, it’s an object lesson in just how hard and complicated it is to effect change in aviation. The regulatory system is inflexible and un-agile – as drone, electronics and third class medical proponents all know…
That said, the most profound words in this story, for me, are that teaching Dr. Williams aviation risk management training “needed to start with his first flight lesson”. Amen! I recently published an article [http://wp.me/p3EbK5-xW] on the subject (in response to an article in Aviation Safety magazine) that advocates making personal and environmental risk management a checklist procedure – like just about every other flight stage. The pilot is the most important, versatile and unreliable system in the whole airplane, and yet we still manage ourselves with a ‘kick the tyres and light the fires’ attitude. THAT needs to change.

It would not have saved Dr. Williams life. All the initiatives in the world, like FAASafety, ACS, the various risk-management tools web apps released recently, all the flight instructors’ best efforts, would have made no difference. You cannot “teach” someone to be safety-conscious, or to have the right attitude. They either have it or they don’t. Some people, I am afraid, are simply irresponsible by nature. I personally know people who are not stupid, but who have demonstrated such irresponsibility while driving that I would never take them flying even as a rear-seat passenger. Dr. Williams sounds to me to be someone like John-John Kennedy, who was warned by many with more experience than him not to take the flight that killed him. So are initiatives that teach risk-management useless? No. They are very useful, but not because they save lives, because they cannot. Their participants have low accident rates because people who by nature are responsible and careful and thus not prone to accidents gravitate to them. The programs are good because they make it much easier for those who are responsible risk managers to do just that. Above and beyond teaching people to operate an aircraft safely to the best of your ability, you should see your role as CFI to be making safe flying easier, for those responsible enough to listen, rather than trying to teach away irresponsibility.

Sorry to hear of your loss.
Glad to hear of the improvements – It’ about time the test were up-dated and made relevant.
My CFI up here in Canada insisted on learning all about safety and how to stay out of and get out of trouble mentally and especially in the air – actually doing it.

John,
Thanks for driving these important changes in exam relevance. It will likely make a real difference.
I feel compelled to point out a factor that more directly contributed to Dr Williams demise than his not receiving a private lecture- his character/personality flaws quite common to a subset of physician specialists. Namely, arrogance and an apparent (false) belief that listening and learning are for lesser mortals. An “extra” sidebar lecture or conversation from you would very likely have been met with the same refusal to listen that the Flight Service Station folks experienced.
Aviation, like radiology, is complex, important, and very risky when practiced by those convinced they already have the answers.
Best regards,
Tom

HI John,
Congratulations on your endeavours to make the U/S system relevant and practicle.
As a private pilot and Aviation Medical Examiner in Australia, I fear, after reading your article, that even if all this had been in place, Dr Williams may still have killed himself.
I get the feeling from your article that his judgment was not normal. He most probably was subtly impaired. Any pilot who could come so close to killing himself, and not have the insight to realise it, is impaired. I am thinking of early dementia such as Alzheimers disease. Unfortunately it strikes the best and brightest, and some of the earliest effects are reduction in fine judgement and self awareness. It is especially difficult to acknowledge for those whose strength has been their intellect.
The subtle clues you mention in his general behaviour in class may have been an early manifestation.
Unfortunately, such subtle impairments are very difficult to diagnose, and any pilot on his best behaviour can get passed the medical examiner. Add to this the fact that large amounts of money and personal effort and pride are invested in being a pilot, it is easy to see how an approach such as ” Hi John. Several of us have concerns re your behaviour, and we would like to prevent you killing yourself by stopping you flying” will be met with open hostility, and fiercely defended.
I know of similar cases in Australia. I do not know the answer to this. In Dr Williams case, we can take comfort in the fact he did not kill anyone else in the accident. If I am correct, he may even have preferred that end to vegetating in a nursing home.
So please continue your efforts to make the system as good as it can be, and improve pilots ability to self dicipline, but stop beating yourself up about your inability to save Dr Williams. I doubt anyone could have done that.
We need much better ways of diagnosing subtle impairments and personality disorders that reduce critical judgment, and until we have these, there will be more Dr Williams’s.

Keep up the good work.As a horrific crash survior,things happen.Risk is always there.I thank good training,experience,and all the medical community for forestalling the services of the funeral director.Engine failure just after take off.

First of all. Thanks for having all that compassion. When you say it almost drove you out of the business, it shows me how much you care. That I think is what drives your passion to make things in the air more safe. All of your efforts in the world would not have saved Dr. Williams. He was
destined to fail. I am a money manager and I find that some people are just “too smart” to listen.
They are unteachable and choose to be so. They are always in a hurry and in aviation that is a recipe for disaster. All Doctors are smart and very goal driven as are many other professionals.
The problem arises that some think that their skill and knowledge in one area automatically transfers to every other area. To they are convinced they don’t have to do the work or pay attention to others to learn something new.

John, there is nothing you could have done to save Dr Williams. He chose his own path.
When you run across the next one, and you will, you have to confront him big time and
shock him or her out of their normal routine. That is the only thing that might get their
attention. Plus you get the added benefit of anyone else that is in earshot that you are
not messing around when it comes to safety. By the way passed check ride and the written with your material. IFR next step. Thanks for all you do.

Great article. Another physician here :-). It is really sad to see so many bright people loose their lives. I have about 160 hours of flight time and I passed my check ride about a year ago with 135+ hours of flying. Soon after I enrolled into an IFR program. So far, I have had about 20 hours of sim. Time and about 20 hours of REAL IMC flight time. Guess what, I still don’t fly solo. In my experience, too many people with limited knowledge are granted certificates. Learning to fly doesn’t end with a certificate, but it really begins when someone from the FAA shakes your hand. My point is that I don’t believe I am significantly less skilled than the next freshman pilot, but I am not also in a rush like Dr. Smith to fly like the professionals. Flying is a work in progress. The possibilities of risk are limitless, but some things are more likely to popup than others. Learning to mitigate risk not only comes from books and interacting for a limited time with your instructor, it really matured with number of hours flown with someone that can help fill in knowledge gaps. At the end of the day, slow flight training with an instructor, adding flight time, reading cases reports, following the NTSB’s report analysis, and knowing your academic and practical knowledge is what will mitigate your risks.

These modifications to the training system are due though I suspect the good doctor would not have benefitted from the changes had they been in place. This is because, according to your article, the doctor actually had the benefit of a risk assessment before he departed on the return leg. It came in the form of the relieved flight centre staff ‘begging’ him to stay to talk. He dismissed this request due to a compulsion to make a speaking engagement. So the real cause of the accident was the pilots inability to diffuse personal ‘impulses’ once they are active. This was seen during the earlier training. As an instructor, I solve the same issue by providing parallel tuition on how to diffuse mind narrowing impulses whilst also delivering the skills training. This parallel education helps mitigate against the personal habits that so often come will ‘goal driven’ or achievement driven individuals. When they understand themselves better they have a far greater chance of identifying when this spell is active. The reason the military model is effective in this regard is that aside from the excellent training itself, trainees are coached through so many unexpected error iterations they are left with the impression that they can always be wrong. Thus their ears tend to remain open to external input even when compelled to complete a mission.

There are lot of MD s . Some degree holders are (MD)mentally disturbed . Just because someone has MD that does not mean they are smart or got other skills, like flying. Lot of MD s will not know how to jump start a car. Well, not many new pilots can tell how many CFI s are building time and money than training.
Do not know how many start and never finish flying. At least I saw during my training lot of dragging by CFIS and not teaching properly.
Learned lot of things on my own by listening to John and Martha king’s tapes. Learned about their existence by readinAOPA magazine. As far as I am conserned, every kid , even he never wants to be a pilot, just to get general knowledge about flying and weather should listen to John and Martha kings tapes.

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There are lot of MD s . Some degree holders are (MD)mentally disturbed . Just because someone has MD that does not mean they are smart or got other skills, like flying. Lot of MD s will not know how to jump start a car. Well, not many new pilots can tell how many CFI s are building time and money than training.
Do not know how many start and never finish flying. At least I saw during my training lot of dragging by CFIS and not teaching properly.
Learned lot of things on my own by listening to John and Martha king’s tapes. Learned about their existence by readinAOPA magazine. As far as I am conserned, every kid , even he never wants to be a pilot, just to get general knowledge about flying and weather should listen to John and Martha kings tapes.